Virtual Consultation "*" indicates required fields Hiddenrsi-client Hiddenrsi-campaign First Name* Last Name* Age*Gender* Female Male None Pronouns She / Her / Hers He / Him / His They / Them / Their Weight Height Phone*Email* SMS Consent I would like to opt-in for SMS messaging.How would you like us to respond?* Phone Email Areas of Concern & Procedures You are Considering:*When are you hoping to have this procedure done?*ASAP3 months6 months +Is there an event that is motivating you? Have you had cosmetic surgery before? Yes No If yes, please indicate surgical procedures How long have you been thinking about cosmetic surgery?*Less than 3 monthsAbout 6 months1-2 YearsMore than 2 yearsOn a scale of 1-10, how important is this surgery to you?* What are your expectations & concerns of this procedure?*Where are you in your decision-making process?*I'm just starting to think about itI've started researching procedures and doctors in my areaI've done my research, but I have more questionsI've decided I want the procedure, I'm just waiting for a good timeI'm ready to book my procedure nowDo you now or have you ever had (Please check all that apply) Heart Trouble Heart Attack Heart Pain Palpitation or Irregular Pulse Extra Heart Beats Stroke Hypertension Blood Pressure Abnormalities Abnormal EKG Rheumatic Fever Heart Failure Digitalis Treatment Shortness of Breath Chest Pain Asthma Bronchitis Pneumonia Tuberculosis Smokers Cough Emphysema Coughing or Spitting of Blood Hay Fever Major Allergies Palsy or Paralysis Nervous Breakdown Nervous Disorder Insomnia Drug Habit Self-Destructive Tendencies Psychiatric Hospitalization or Care Thyroid Problems Kidney or Renal Disease Heart murmur Piercing other than the ears Positive blood test for: HIV, AIDS, Hepatitis Missed or irregular last menstrual period Family history of cancer, heart trouble, stroke Glaucoma or Eye Problems Visual Disturbances Wear Glasses/Contacts Other Eye Problems Hepatitis (A, B, or C) HIV, AIDS Gallstones or Gallbladder Trouble Cirrhosis of the Liver Alcoholism or Drug Dependency Esophageal Varices Frequent Indigestion Ulcers Gastritis Colitis Problem Constipation Vomiting Blood Tarry or Bloody Bowel Movements Hemorrhoids Goiter or Thyroid Disorders Diabetes Skin Disorders Arthritis Fracture of Neck or Spine Bleeding Tendency or Disorder DVT (Deep Vein Thrombosis), Blood Clots Airway Obstruction (Nasal) Breast Cysts, Tumors, Abscesses Nipple Discharge (Apart from Normal Lactation) Kidney Disorder Blood Transfusion Seizures or convulsions or fainting spells Black outs Dentures, bridges, capped teeth or crowns Loose teeth Cosmetic bonding to teeth Any family members with bleeding problems Any family members with anesthesia problems Please list all present medications, including birth control pills, hormones, and vitamins, herbal medication, diuretics, weight loss drugs. Include over-the-counter medications.Do you have an allergic reaction to any medication?* Yes No Which?* Do you react abnormally to any medication?* Yes No Which?* Have you, or any member of your family, ever had any difficulties with any medications, drugs, or gases used for anesthesia?* Yes No If yes, when and where?* Have you ever been on cortisone or steroid treatment?* Yes No When?* Do you have cocktails regularly, or consume regular amounts of alcoholic beverages, including beer, wine, or other alcohol?* Yes No If so, how much?* Do you smoke?* Yes No If so, how much?* For how long?* Are you pregnant?* Yes No When was you last normal menstrual period? How many pregnancies? Births? Breast Fed?* Yes No For how long?* CHILDREN (gender and ages/birthdays)When was your last physical exam? By whom? When was your last eye examination? By whom? When and where was your last chest x-ray? EKG? Who is your personal physician, if any? (Please list all physicians presently caring for you)Have you ever been under psychiatric care?* Yes No When & Why?* Have you had any recent blood work done?* Yes No Where?* Is there anything else you think the doctor should know?Please list all hospitalizations and surgeries, including procedures done for cosmetic reasons:SURGICAL OPERATIONS (include where, when and why for each surgery)HOSPITALIZATIONS (include where, when and why for each admission)How were you referred to Dr.Rubinstein? (Please check all that apply) Friend Another Doctor You have been a patient of ours Radio TV Our website YouTube Facebook Instagram SnapChat Web search/Google Other PLEASE USE THE UPLOAD BUTTON BELOW TO UPLOAD PHOTOS TO SEND TO US Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 20 MB. To make the most of your virtual consultation, do your best to submit your photographs in the following format. This will allow our doctors to make the most comprehensive assessment. 1. Use a solid background. 2. Take one frontal photo with the face or body centered and looking straight. 3. Take at least one, preferably two profile photosFile Upload*Max. file size: 20 MB.File UploadMax. file size: 20 MB.If you are interested in a breast augmentation, chin augmentation or rhinoplasty, we offer virtual simulations of possible results.By checking this box you agree to the Terms of Use listed here* I agree to the privacy policy.Communications through our website or via email are not encrypted and are not necessarily secure. Use of the internet or email is for your convenience only, and by using them, you assume the risk of unauthorized use. By checking this box you hereby agreeSIGNATURE* DATE* CAPTCHANameThis field is for validation purposes and should be left unchanged.
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